Our aim was to explore whether a CRT module was acceptable to AN patients, secondly, to establish whether cognitive exercises changed set shifting task performance and finally, based on our results, to modify the CRT manual for a larger pilot study.
As far as the neuropsychological performance was concerned, the observed medium to large effect sizes suggests that targeted cognitive flexibility exercises change performance in shifting tasks on follow up assessment. Comparison with the retrospective data obtained from patients in the same clinical setting and using the same neuropsychological tasks with a treatment as usual group, shows small effect sizes in set shifting performance. It is not possible to draw firm conclusions given the small size of this case series compared against the larger retrospective comparison group.
Based on a) the practical application of the tasks, b) retrospective observations of the cases on supervision and c) qualitative analysis feedback letters, we have established that the treatment package is acceptable. For example, none of the patients dropped out, all commented on the relevance of the exercises and gave useful recommendations for improvements. Therapists reported that the intervention was sufficiently gentle to allow acutely ill patients to access it and further commented that the simplicity and structure of the sessions were helpful in establishing a good relationship with the patient.
One of our aims was to develop and tailor exercises from established interventions and adapt them to produce a CRT intervention for AN patients. This was done in a number of ways from adding new tasks to adjusting the delivery of the intervention. For example, a monitoring form was used to report patient performance (scoring 1–3 poor/good) and exercises were timed. However, this was found to be ineffective without a sufficient baseline and therefore it is proposed that future monitoring of sessions should be done qualitatively by asking the patient questions throughout the session and recording their answers. These will include "What did you learn from these tasks?", "What do the tasks show you about your thinking style?" These questions should allow the patient to internalise the strategy they have used as well as reflect on the tasks in terms of thinking style. The evaluation questions should also provide the therapist with a better insight into the patients thinking style and hence direction on how to proceed in the specific task and also in the sessions.
It was also proposed, based on qualitative feedback by patients (see results), that the therapist should encourage the patient to make connections between thinking styles apparent whilst doing the tasks to real life scenarios. To this end it is proposed that the therapist ask the patient after each task "How does your thinking style [in the task] relate to real life?" As well as making these connections, behavioural tasks that can be undertaken outside of the sessions can be introduced in later sessions to intensify the learning experience. These tasks can be discussed in the session and then carried out by the patient in their own time. Feedback can then be given to the therapist in the following session. A list of behavioural tasks will be included in the updated manual. From the four patients we learned about the possible behaviours patients could try successfully. A few examples of these are reading a newspaper in a different order, taking a different route to proposed destination, using a different mobile phone ring-tone, changing their night time routine, cleaning their teeth with their non dominant hand and, making-up a headline from a newspaper article. Patients were able to carry out such tasks, and it gave them a sense of achievement and intensified the learning experience gained in the laboratory setting.
Therapists' observations and patients' comments have also helped us to improve the module by including extra exercises related to set shifting eg switching attention and embedded words whereby a patient reads through a paragraph of text switching between words relating to 'hot' and 'cold' topics. Other switching tasks that have been added include pictures of objects with an incongruent word written on top and pictures of clock faces where it is required to switch between a 12 hr and a 24 hr clock.
One other way in which the case series has lent to further development of a tailored module comes from the task entitled geometric figures. Therapists found that all four patients found this task quite problematic, because when dictating how to draw the geometric shape, all patients provided unnecessary details and this made interpretation of drawing the figure difficult. This clinical observation is in accord with research evidence that has shown that people with AN pay extensive attention to detail [23
]. This poor organizational strategy may lead to difficulties in seeing the overall context. In AN, this strategy is not only present in relation to food, but also to other aspects of life, such as work and homework. To help remediate this thinking style and improve global thinking, the revised manual will include two additional tasks to the geometric figures. For example, a task which requires big pieces of written information such as a letter to be made into a headline or a text message and secondly, a task which requires thinking about prioritising information.